Provider Demographics
NPI:1235596990
Name:OHIO STATE UNIVERSITY OUTPATIENT PHARMACY
Entity Type:Organization
Organization Name:OHIO STATE UNIVERSITY OUTPATIENT PHARMACY
Other - Org Name:THE OHIO STATE UNIVERSITY OUTPATIENT PHARMACY AT THE CCCT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:DELISLE
Authorized Official - Suffix:
Authorized Official - Credentials:SCD, FACHE
Authorized Official - Phone:614-293-9806
Mailing Address - Street 1:460 W 10TH AVE
Mailing Address - Street 2:ROOM L012E
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1240
Mailing Address - Country:US
Mailing Address - Phone:614-685-1672
Mailing Address - Fax:614-366-0097
Practice Address - Street 1:460 W 10TH AVE RM L012
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-5920
Practice Address - Fax:614-366-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-26
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
OH225938503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158015OtherPK
OH0200894Medicaid